HEART Score Safe for ED Evaluation of Chest Pain

NEW YORK (Reuters Health)—Use of the HEART score for evaluating patients with chest pain in the emergency department (ED) is not associated with increased major adverse cardiac events, compared with usual care, according to a study in nine Dutch hospitals.

“The routine use of the HEART score during the initial assessment of chest pain patients at the emergency department was just as safe as usual care,” Dr. Judith M. Poldervaart from University Medical Center Utrecht told Reuters Health by email. “It is likely that with increasing acceptance, confidence, and experience with the HEART score, the impact on health care resources and costs will increase.”

The History, Electrocardiogram, Age, Risk factors, and initial Troponin (HEART) score is used to stratify patients with chest pain according to their short-term risk of major adverse cardiac events (MACE). Its effect on daily practice is unknown, so some clinicians remain reluctant to adopt it for regular use.

Dr. Poldervaart and colleagues investigated the safety of using the HEART score in a cluster randomized trial. All nine hospitals started with an initial period of usual care and, at intervals of six weeks, hospitals switched in a randomized order to the use of the HEART score until all hospitals had crossed over. A score of 7 to 10 put patients in a high-risk group for which prompt invasive treatment was advised. Hospitalization for observation and investigation was recommended for the intermediate-risk group (score of 4 to 6). The recommendation for patients with a score of 3 or less was reassurance and discharge without further diagnostic testing, including no second troponin measurement; however, a second troponin test was performed the same or next day while the patient was ambulatory. At their discretion, however, physicians could overrule the score’s recommendation and admit a patient with a low score.

Most patients (47%) received an intermediate HEART score, 39 percent received a low score, and 11 percent received a high score. The six-week cumulative incidence of MACE was 18.9 percent among 1821 patients receiving HEART care and 22.2 percent among 1827 patients receiving usual care, a difference that was within the prespecified noninferiority margin, according to the April 25th Annals of Internal Medicine report.

There were no major differences between HEART care and usual care in the use of healthcare resources, although there was a small decrease in the proportion of patients who underwent exercise stress ECG, nuclear imaging, and coronary angiography during HEART care.